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Foldscope Diagnostic Accuracy and Feasibility of I
Foldscope Diagnostic Accuracy and Feasibility of I
Abstract
Background: Malaria has been an important public health all over the globe. Although conventional light microscopy is the gold standard of
diagnosis, light microscopes are heavy, fragile, costly, and electricity dependent. Rapid diagnostic tests (RDTs) have become more popular
but perform badly in temperate climate. This is because the RDT kits require maintenance of cold chain for its optimal use. In this regard,
there is a recent interest in handheld malaria microscopy at the point of care in the field setting. Foldscopes are cheap, handy, nonfragile, and
use mobile camera for illumination. The purpose of the study was to find whether foldscope can be used in the national vector borne disease
control program (NVBDCP) in India. Methods: Ten laboratory technicians were trained in identifying malaria parasites using foldscope
and their mobiles. Later, they were provided with unassembled foldscope to document their test results for the preidentified malaria slides.
The blood smears were stained as per the protocol of NVBDCP. The report of the index test (foldscope microscopy) was compared with the
reference test (conventional microscopy). Results: The sensitivity and specificity of the index test was found to be 13.3% (6.257–26.18),
specificity of 97.78% (88.43–99.61), positive predictive value 85.71% (48.69–97.43), and negative predictive value 53.01% (42.38–63.38).
The devise failure rate and test failure rate were 20% and 11.7%. The kappa agreement between the index and reference microscopy was only
11% and the McNemar P < 0.01. Conclusion: The ×400 foldscope at its present magnification and illumination cannot be utilized in the field
under NVBDCP.
Keywords: Field study in malaria, foldscope, handheld microscope, malaria slide examination, malaria, national vector borne disease
control program
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114 © 2021 Journal of Microscopy and Ultrastructure | Published by Wolters Kluwer - Medknow
Gupta, et al.: Foldscope and its utility in malaria control program
entry in the field of malaria microscopy. Foldscopes are failure. Device failure was defined by the inability of the field
origami‑based paper microscopes developed by Dr. Manu technician to get any image of the slide and test failure was
Prakash and team at Stanford University.[3] Foldscopes are defined by the inability of the field technician to report positive
cheap about 500 Indian national rupees, light about 10 g, and or negative for malaria parasite.
easy to carry in a laboratory coat which uses mobile flashlight
for illumination.[3] It is based on the principles of optical
Analysis
The diagnostic screening test was evaluated by constructing a
design and origami. The sample is mounted on a slide and
2 × 2 table after excluding the test failure cases. The table was
viewed while panning and focusing with the operator’s thumb
finally analyzed by OpenEpi Version 3. Kappa agreement and
with a magnifying scalability of 140–2180 times without the
McNemar’s two‑sided P value were calculated by IBM SPSS
requirement of immersion of oil as in Figure 1.[3]
Statistics Version 24. The confidence interval was set at 95%
Most of the handheld microscopes including foldscope and level of significance P < 0.05.
have been studied in controlled laboratory settings and by
experienced hands. There are absolutely scanty field‑based Results
studies for malaria with handheld microscopes. In this context,
the present study was undertaken to evaluate the diagnostic Out of the total 102 MP slides, 49 cases were positive and
accuracy of origami‑based paper foldscope (index test) 53 cases were negative for MP in reference microscopy. Out
in comparison to the conventional binocular bright field of the total 49 positive cases in reference microscopy, only
microscope (reference test) and its feasibility to use for national 6 slides were positive by index microscopy test (true positive),
malaria control program in India. 39 cases were reported to be negative (false negative), and
4 cases could not be commented either positive or negative. Out
of the total 53 negative cases in reference microscopy, 44 slides
Methods were negative by index microscopy test (true negative), 1 case
Design was reported to be positive (false positive), and 8 cases could
This was a cross‑sectional diagnostic accuracy and feasibility not be commented either positive or negative. The values
study. of sensitivity, specificity, positive predictive value, negative
predictive value, and positive and negative likelihood ratios
Setting are provided in Table 1.
The study was conducted at the Microbiology Laboratory
of the All India Institute of Medical Sciences, Bhopal, and The device failure rate was 20% (2/10), meaning that 2 of the
malaria microscopy centers of Bhopal district recognized by technicians out of the total 10 technicians required help later for
the Government of MP under the national vector borne disease assembling the foldscope. Test failure cases were 12 in number
control program (NVBDCP) of the state. meaning that the index microscopy could not comment on either
positive or negative test. The test failure rate was 11.7% (12/102).
Sampling and sample size The various diagnostic test characteristics are provided in Table 1.
The slide positivity rate was approximately 0.5% for malaria The Kappa measure of agreement between the reference and index
parasite. [1] With an expected malaria slide positivity of microscopy tests was 11.1% (0%–22.3%). The McNemar 2‑sided
approximately 0.5, sensitivity of 90% and specificity of 90%, P was significant (<0.001).
and precision of 90% with a confidence interval of 95%, the
required sample size was calculated to be 102. The same
number of samples were collected for the study purpose.
Discussion
A consecutive sampling technique was used. Handheld microscopy at the point of care is the need of
Study procedure
The technicians identified by NVBDCP of the state were Table 1: Characteristics of the index test
provided a full 1‑day hands‑on training to use foldscope Parameter Estimate (%) 95% CIs (lower-upper)
by arranging a workshop. They were trained to the level Sensitivity 13.33 6.257-26.18
of agreement for 90% to detect positive and negative Specificity 97.78 88.43-99.61
results for malaria parasites using both the reference Positive predictive value 85.71 48.69-97.43
microscope (conventional light microscope) and index Negative predictive value 53.01 42.38-63.38
microscope (×400 foldscope). Later, they were provided Diagnostic accuracy 55.56 45.27-65.38
unassembled foldscope and advised to comment on the slides Likelihood ratio of a 6 0.1011-356.1
positive test
preidentified by NVBDCP. Both the Ethylene Diamine Tetra
Likelihood ratio of a 0.8864 0.8421-0.933
Acetic acid (EDTA) mixed venous blood smear or peripheral negative test
blood smear slides were accepted for the study. The blood Kappa agreement (%) 11 0-23
smears were stained by Jaswant Singh–Bhattacharji (JSB) stain Level of significance <0.001
as per the protocol of NVBDCP. They were asked to document McNemar P
observations as positive/negative/device failure and test CI: Confidence interval
et al. Mobile phone microscopy for the diagnosis of soil‑transmitted 13. Naqvi A, Manglik N, Dudrey E, Perry C, Mulla ZD, Cervantes JL.
helminth infections: A proof‑of‑concept study. Am J Trop Evaluating the performance of a low-cost mobile phone attachable
Med Hyg 2013;88:626‑9. microscope in cervical cytology. BMC women’s health 2020;2:1-6.
5. Ephraim RK, Duah E, Cybulski JS, Prakash M, D’Ambrosio MV, 14. Zhang YS, Santiago GT, Alvarez MM, Schiff SJ, Boyden ES,
Fletcher DA, et al. Diagnosis of Schistosoma haematobium infection Khademhosseini A. Expansion mini‑microscopy: An enabling
with a mobile phone‑mounted Foldscope and a reversed‑lens CellScope alternative in point‑of‑care diagnostics. Curr Opin Biomed Eng
in Ghana. Am J Trop Med Hyg 2015;92:1253‑6. 2017;1:45‑53.
6. Coulibaly JT, Ouattara M, D’Ambrosio MV, Fletcher DA, Keiser J, 15. Rajchgot J, Coulibaly JT, Keiser J, Utzinger J, Lo NC, Mondry MK,
Utzinger J, et al. Accuracy of mobile phone and handheld light et al, Bogoch II. Mobile-phone and handheld microscopy for neglected
microscopy for the diagnosis of schistosomiasis and intestinal protozoa tropical diseases. PLoS neglected tropical diseases 2017;11:e0005550.
infections in Côte d’Ivoire. PLoS Negl Trop Dis 2016;10:e0004768. 16. Boppart SA, Richards‑Kortum R. Point‑of‑care and point‑of‑procedure
7. D’Ambrosio MV, Bakalar M, Bennuru S, Reber C, Skandarajah A, optical imaging technologies for primary care and global health. Sci
Nilsson L, et al. Point‑of‑care quantification of blood‑borne Transl Med 2014;6:253rv2.
filarial parasites with a mobile phone microscope. Sci Transl Med
17. Holmström O, Linder N, Ngasala B, Mårtensson A, Linder E, Lundin M,
2015;7:286re4.
et al. Point-of-care mobile digital microscopy and deep learning for the
8. Coulibaly JT, Ouattara M, Keiser J, Bonfoh B, N’Goran EK,
detection of soil-transmitted helminths and Schistosoma haematobium.
Andrews JR, et al. Evaluation of malaria diagnoses using a handheld
Global health action 2017;10:1337325.
light microscope in a community‑based setting in rural Côte d’Ivoire.
18. Wang W, Liu H, Yu Y, Cong F, Yu J. Rapid Yeast Cell Viability Analysis
Am J Trop Med Hyg 2016;95:831‑4.
9. Saeed MA, Jabbar A. “Smart diagnosis” of parasitic diseases by use of by Using a Portable Microscope Based on the Fiber Optic Array and
smartphones. Journal of clinical microbiology 2018;56. Simple Image Processing. Sensors 2020;20:2092.
10. Orth A, Wilson ER, Thompson JG, Gibson BC. A dual-mode mobile 19. Hernández‑Neuta I, Neumann F, Brightmeyer J, Ba Tis T,
phone microscope using the onboard camera flash and ambient light. Madaboosi N, Wei Q, et al. Smartphone‑based clinical diagnostics:
Scientific reports 2018;8:1-8. Towards democratization of evidence-based health care. J Intern Med
11. Abstracts from the International Science Symposium on HIV and 2019;285:19‑39.
Infectious Diseases (ISSHID 2019): Infectious diseases. BMC Infect 20. Prakash R, Prakash K. Virtual microscopy made economical and
Dis 2020;20 Suppl 1:324. effortless using the Foldscope and a smartphone with screen mirroring.
12. Accuracy of Mobile Phone and Handheld Light Microscopy for the J Oral Maxillofac Pathol 2019;23:292‑4.
Diagnosis of Schistosomiasis and Intestinal Protozoa Infections in 21. McGenity TJ, Gessesse A, Hallsworth JE, Garcia Cela E,
Côte d’Ivoire. Available from: https://journals.plos.org/plosntds/ Verheecke‑Vaessen C, Wang F, et al. Visualizing the invisible: Class
article?id=10.1371/journal.pntd.0004768. [Last accessed on 2020 Jul excursions to ignite children’s enthusiasm for microbes. Microb
09]. Biotechnol 2020;13:844‑87.